In an adult with obsessive‑compulsive disorder currently taking escitalopram (Lexapro) 20 mg daily, what is the next best medication step?

Next Steps for OCD Treatment on Lexapro 20mg

Increase escitalopram to 30mg daily and reassess after 8-12 weeks at this higher dose before considering any medication switches or augmentation strategies. 1, 2

Optimize Current SSRI Therapy First

Your patient is on escitalopram 20mg, which is the FDA-approved dose, but OCD requires higher SSRI doses than depression or other anxiety disorders. 1, 3 The evidence strongly supports dose escalation before declaring treatment failure:

• Escitalopram can be safely increased to 30-50mg daily for OCD, with a randomized controlled trial demonstrating that 20mg was superior to placebo while higher doses showed additional benefit. 2, 3
• In an open-label study of 67 OCD patients, those who didn't respond to 20mg were escalated to a mean dose of 33.8mg daily with significant improvement (P<0.001) and excellent tolerability—only dry mouth (12%) and decreased libido (32%) were reported, with zero discontinuations during the high-dose phase. 2
• Allow a full 8-12 weeks at the target dose before concluding treatment failure, as maximal improvement typically occurs around week 12 or later. 1, 3

Add Cognitive Behavioral Therapy Immediately

CBT with Exposure and Response Prevention (ERP) should be added to continued pharmacotherapy regardless of medication changes, as this combination produces superior outcomes compared to medication switches or augmentation alone. 1

• Meta-analyses demonstrate that adding CBT to pharmacotherapy has larger effect sizes than augmentation with antipsychotics. 1
• Patient adherence to between-session ERP homework is the strongest predictor of good outcomes. 1

If Adequate SSRI Trial Fails (After 8-12 Weeks at 30-50mg)

First-Line Augmentation Options:

Antipsychotic augmentation has the strongest evidence:

• Aripiprazole 10-15mg or risperidone are recommended by the American College of Psychiatry as having the strongest evidence for SSRI-resistant OCD. 1
• Approximately one-third of SSRI-resistant patients show clinically meaningful response to antipsychotic augmentation. 1
• Monitor metabolic parameters (weight, glucose, lipids) when using antipsychotics. 1

Glutamatergic agents as alternative augmentation:

• N-acetylcysteine (NAC) has the strongest evidence among glutamatergic agents, with 3 out of 5 RCTs showing superiority to placebo. 1
• Memantine has demonstrated efficacy in several trials. 1

Second-Line Options:

• Switch to clomipramine 150-250mg daily if the patient fails at least one adequate SSRI trial, though this is reserved due to inferior tolerability (anticholinergic effects, cardiac monitoring required). 1
• Consider switching to a different SSRI (sertraline 150-200mg, fluoxetine 60-80mg, paroxetine 60mg) as individual responses vary. 1, 3

Critical Monitoring Points

• Early response by weeks 2-4 predicts ultimate treatment success—improvement in quality of life, social functioning, and work productivity are positive prognostic signs even before full symptom reduction. 1
• Assess for serotonin syndrome when changing or combining serotonergic medications, particularly during dose escalation. 1
• Treatment duration should be 12-24 months after achieving remission due to high relapse rates after discontinuation. 1

Common Pitfalls to Avoid

• Do not prematurely switch medications before completing an adequate trial (8-12 weeks at maximum tolerated dose). 1
• Do not use depression-level SSRI doses for OCD—this is inadequate dosing that leads to apparent "nonresponse" and unnecessary medication cycling. 1
• Escitalopram 20mg showed superiority to placebo as early as week 6 in controlled trials, but full response requires patience through week 12. 3